Impact of comorbidity on health-related quality of life in men undergoing radical prostatectomy: Data from CaPSURE

doi:10.1016/j.urology.2005.09.006

Urology

Volume 67, Issue 3, March 2006, Pages 559-565

https://doi.org/10.1016/j.urology.2005.09.006 Get rights and content

Abstract

Objectives

Comorbidity is one of many factors that may affect health-related quality of life (HRQOL) in men with prostate cancer. We hypothesized that the number and type of comorbidities negatively affect HRQOL in men undergoing radical prostatectomy.

Methods

We reviewed HRQOL outcomes before and up to 2 years after radical prostatectomy for men with localized prostate cancer in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a longitudinal disease registry. This analysis focused on 856 men who completed a pretreatment survey and at least one posttreatment survey. HRQOL was assessed using the University of California, Los Angeles, Prostate Cancer Index (six subscales) and the Medical Outcomes Study 36-Item Short Form questionnaire (eight subscales and two summary scales). The associations between HRQOL and the number and type of comorbidities were analyzed using repeated measures during a 2-year follow-up period.

Results

Preoperatively, men with no comorbidities had greater HRQOL scores than did men with comorbidities for physical health and disease-specific measures, but not for mental health measures. Only sexual function and the physical component summary scores showed a significant interaction between the number of comorbidities and time (P <0.01 and P = 0.03, respectively). Significant interactions with time were observed for other urinary conditions, gastrointestinal disease, heart disease, and hypertension on at least one HRQOL domain.

Conclusions

Men with comorbidities had worse HRQOL scores than men without comorbidities, both before and after radical prostatectomy. However, with two exceptions, the scores declined at similar rates after surgery. Specific comorbidities also had an association with certain HRQOL domains. Therefore, during preoperative counseling, clinicians should consider a patient’s number and type of comorbidities.

Section snippets

Material and methods

We drew subjects from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a longitudinal, observational prostate cancer disease registry that includes patients with biopsy-proven adenocarcinoma from 40 urology practices nationwide. Subjects submit semiannual HRQOL questionnaires until death or withdrawal from the study. All participants provided informed consent before study enrollment. Additional details of the project method have been previously reported.⁹

All subjects

Results

The 856 men included in this analysis were of similar age and marital status as other men receiving RP who were not included in the analysis. However, the men in this analysis were more educated, had higher incomes, were more likely to be white, and had a lower risk of disease than other men undergoing RP.

These 856 men contributed 3140 questionnaires (or 3.7 per person) permitting us to examine longitudinal changes in HRQOL. The median follow-up time after surgery was 16 months (range 3 to 30).

Comment

We began the study with two hypotheses. First, we hypothesized that men with more comorbid conditions would have worse HRQOL than men without comorbidities at baseline, and we found this to be true. Our second hypothesis was that these differences would be maintained over time; here our findings were mixed. In almost all cases, the HRQOL scores for men with comorbidities were worse at each point, and this difference was constant over time.

However, for sexual function and the physical component

Conclusions

Men with more comorbidities have a worse quality of life before and after RP. However, with two exceptions, the HRQOL scores declined at similar rates in men with and without comorbidities. In addition, specific comorbidities, such as hypertension, heart disease, GI disease, and urinary conditions, were associated with declines in particular HRQOL domains.

References (17)

J.C. Hu et al.
Predicting quality of life after radical prostatectomyresults from CaPSURE
J Urol
(2004)
F.M. Fang et al.
Health-related quality of life for nasopharyngeal carcinoma patients with cancer-free survival after treatment
Int J Radiat Oncol Biol Phys
(2002)
D.P. Lubeck et al.
The CaPSURE databasea methodology for clinical practice and research in prostate cancer
Urology
(1996)
R. Jaeschke et al.
Measurement of health statusascertaining the minimal clinically important difference
Control Clin Trials
(1989)
G. Lyketsos et al.
Psychological characteristics of hypertensives and ulcer patients
J Psychosom Res
(1982)
K.L. Schwartz et al.
Continued undertreatment of older men with localized prostate cancer
Urology
(2003)
P.N. Post et al.
Comorbidity in patients with prostate cancer and its relevance to treatment choice
BJU Int
(1999)
C.A.C. Schag et al.
Quality of life in adult cancer survivors of lung, colon, and prostate cancer
Qual Life Res
(1994)

There are more references available in the full text version of this article.

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We conducted a systematic literature search for January 2005-March 2017 following PRISMA guidelines, including longitudinal studies measuring disease-specific PROs in localized prostate cancer patients with a follow-up from pre- to post-treatment (≥1 year). Two reviewers independently extracted data and assessed risk of bias. The study is registered in PROSPERO: CRD42015019747.
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AUS cuff erosion is a challenge for both surgeons and patients. It is well established that urinary incontinence substantially reduces patient health-related quality of life (HRQOL).24,25 Urethral strictures further compound the sequelae of cuff erosion by delaying reimplantation and subsequent recovery of continence.
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Twenty-five of 78 patients manifested a urethral stricture after AUS cuff erosion (32%). More strictures occurred among patients who underwent urethrorrhaphy (40% vs 29% for catheter only and 14% for urethroplasty). Stricture rates did not vary significantly by repair type (P = .2). Strictures occurred significantly more frequently in patients with complete cuff erosions (58%) as compared to partial erosions (25%, P = .037). A trend was detected regarding increased percentage of erosion correlating with increased stricture rate, but this did not reach statistical significance (P = .057). Partially eroded patients were more likely to undergo urethrorrhaphy repair (60%, P = .002).
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Although there are sufficient data on quality of life (QoL) after prostatectomy in the general population, there are few data in patients older than 70 years or in patients with comorbidities. Previous publications on this topic have evaluated QoL in older patients without comparison with younger patients [2], evaluated QoL irrespective of treatment modality [3,4], used retrospective data [5], or had low sample numbers [6]. Radical retropubic prostatectomy is the surgical standard treatment for 75% of patients in Germany (USA: 36%), whereas approximately 25% are treated with robot-assisted prostatectomy (USA: 64%) [7,8].
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The current CaPSURE Investigators are listed in the Appendix.

CaPSURE is supported by TAP Pharmaceutical Products Incorporated, Lake Forest, IL. This research was additionally funded by the National Institutes of Health/National Cancer Institute University of California, San Francisco SPORE Specialized Program of Research Excellence grant P50 C89520.

E. P. Elkin, P. L. Marr, D. M. Latini, M. S. Litwin, and P. R. Carroll are study investigators partially funded by the sponsor of this study, TAP Pharmaceutical Products Inc. M. S. Litwin is also a paid consultant to Sanofi-Synthelabo and Amgen. P. R. Carroll is also a paid consultant to AstraZeneca, Steba Biotech NV, Predicant Biosciences, and Watson Pharmaceuticals and is a meeting participant/lecturer for the International Center for Post-Graduate Medical Education.

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Adult urologyImpact of comorbidity on health-related quality of life in men undergoing radical prostatectomy: Data from CaPSURE

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

Int J Radiat Oncol Biol Phys

Urology

Control Clin Trials

J Psychosom Res

Urology

Comorbidity in patients with prostate cancer and its relevance to treatment choice

BJU Int

Quality of life in adult cancer survivors of lung, colon, and prostate cancer

Qual Life Res

Adult urology
Impact of comorbidity on health-related quality of life in men undergoing radical prostatectomy: Data from CaPSURE